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23 0 obj 22 0 obj Aflacs Premium Life, Absence and Disability Services are available in all states, except Puerto Rico, Guam or the Virgin Islands, and are offered by Continental American Insurance Company (CAIC). /BaseFont /Helvetica-BoldOblique h0cQ^!FY^@5YZ9`C((MZ9iSNHc>@i(/A6Ang=Q>29[%f,N\.ZX(j>Mqs0Q)QK[VqWr`O1c][Ae6
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The employer is required to report disability benefits paid on pre-tax plans on Form 941 and the employee's Form W-2. Gb!'5m[/fJB\_$r.pF?nb0?9.GNU`POZa=?bcjAXQ5kBDO7EHm>6&%47Ab&pW\\Ep0DVbs4$N;\XPZ>cd==.mQbW>ZXE(h&hj!?>RE;`-=j0]K(7>2TZ2c#qP2TZrnnVO>AAO\2\dZ]BV5lN<2g@`o#75u,Z^-1@eCMYZY`nV9iX]Jk15[r)/_I8dD(4^c,bTd,',#!J7^rL)<3a8P7fG%*rf%Dr0X9k_#\a>h%ENsu1N_I/E6"$"4aO%gkZ#_P8u%,_DD4Z3`,&-G'RNJo*@\gVBC#dISL`OXs`X"2c\XYOgQMjo(nU9j@@I>:$?-SG%p\5>K8mf'`2n5g](hjREP0cIi=DlJG%CduFYJX&b.fJg%;BE/2\Y7`WHp'nr&%:J'Y"Od>X7ZKtp1A2/F(Cd$FjNX24)>aWHAi,$d!uihMX'(n_)L`HY6h*Ya>%R%`kI!@VZ@Kj*91XAll1b#)Sj(43C0*ZDYVHW.o&^]8^cs$b>tO5/3)s#"+[I40fCCO0u2)j*3e@/a);GiEC,QcYi&n:D@TcfYcBYeX>jFB"0g]k[qcIUEDh\sY`P3V$amn](*)ZhblK=iC]sei38!J\1:'Sm^g=9F1G?^5X*UTD.c8Kg>?CNpfj;t*;*+5-3+-1$][#p+$s7LY3ds$(WS^3ipt1n?4gpo(-)4hZ]5TSD1c"b62Ae,uI=ht5%%pur?]C"mK+/"n@,G@E!%Tm_Z('e6`@=LQJX>m2u!EdFdln=`n_1KT(Jdtn&@OhFd_-qh%AS.4e_"nG>AmU@I`/XL)S*AH60oN#\=,_M)mR[KZ"p#@QKTXhSQoBW6Pc2r1abgMO4mbWZJ_P.S0Z?CC27h1I4*Xt]'k^P`c1tChMX"]cTFjUN>O%@eLs@rgmWT?ci5AXtahm=GCI0lG41Vu%ET![Pf]&aI:B+JKG^84P$0u2CD+0?/0su!u;km^rug0:2"VI(*%/+bQ/)HNQVs0JlC_#J`D*lKqGe.5CT5W%::0+m=,"tDhT:Jf.Zq_h(jA)][.]!1gIc_g$e.NIY7[Dn[]g&+*Dc(B:jSF2;0_UcSO=hWJLHLeZ$&=Ibr9.GHm'mXS3P2Ek.5Ya!YtUFO)#kgZ.eZ`LC0e]4]aW"'asKdg_Z"5EE^C=)[U)8)55iHZq2>kKE;Zj.Do+X/DSW[g,Q>hSOSQ$%5h_?(@[q&hh1R=9+/)8;"A^Hn>PPi5t$eN5g`uORs-`,rNBc0.X_)BIVn/qs?1NU@,SCi]^G`[P0TK1pr%^qAZJ4DVn/T'u"#MW0u^k8/G"%kaRF,8qKUN? 2 0 obj ;]2"WH3RN-IY-eA348fl;R6]T4%O*^emkHfI8Di4T'&!Ns\94;%b
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<> In NY both group and individual coverage is offered by American Family Life Assurance Company of New York. C)U\u?j:;&T7I/iGm[n\T;_)`gEYqdm*YLN@N-_eg4^hU\]H7Co2_+ugag&:Fd?U>McjOT-(PdfS7Ma7
File a Group Life Insurance or Accidental-Death and Dismemberment Insurance Rider Claim, File a Universal Life Insurance Claim underwritten by Trustmark Insurance Company Claim, File a Universal Life Insurance Claim underwritten by Trustmark Insurance Company, Do Not Sell or Share My Personal Information. 8 0 obj Fill out all of the required fields (these are yellow-colored). Z'qla+"Ni'F7cdihoHcj(u=..e%DbtGJWZF/nB*]I!`;q;hE9aN=iqM2-6r0A.0!kYlX,(D
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Forms are available on our web site at aflac.com. a*7QP2nR!.R_;hRHWlnl#NqY`2;1A,B&CcHbipl%. stream [:'^X
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endstream stream You can provide this information in the designated space on the claim form. /CreationDate (1/24/2023 00:45:44) )lM~> a8BPfZ&sW[D\qX`_,022h,5IoVd[
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If your disability is being extended, you will need to complete the listed Supplemental Claim form. !G5'>m!$kI`%E,=&c9e1!`-(ln6%1Abq7/PK2;m`V,'D51([Fj
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-8KU)@AZCLegJ8ge%BBp0g(_Y&;BmiFJfS%>@Gu7. We pay claims fast. The University is committed to a policy of equal opportunity for all persons and does not discriminate on the basis of race, color, national origin, age, marital status, sex, sexual orientation, gender identity, gender expression, disability, religion, or veteran status in employment, educational programs and activities, and admissions. ;PmE,29/@]Q_gjie3>F*fbNG$7H6^5^trSgt@MX18^JE+B$K
Filing Claims | Aflac Group 46a&g>*Zg/Di4fH;%L. 8,Y5:-bZ-;Z%c':c]*),@W=_c. ([eH#15RQ9*WFJq0`khPI=$2a3*8h8?\)&pGHS--no]E3Z-HiTg
0000054923 00000 n If your injury occurred on the job, a first report of injury filed with your employer must be attached to the completed claim form. Aflac Claim Forms Initial Disability Claim Form Physician's Statement >> *Before filing a critical illness claim online, please ask your physician to complete and return the Physician's Statement Form*. 13 0 obj h0cQ^!FY^@5YZ9`C((MZ9iSNHc>@i(/A6Ang=Q>29[%f,N\.ZX(j>Mqs0Q)QK[VqWr`O1c][Ae6
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Get rid of the routine and create paperwork on the web! >> (V.ea8oM1meVG5&2$R&VHdRmbM`,/jQ'iTTlk_NLi7Pu8>hqB>F6,at#]$=1\UL'_o
55184 Submit or View Your Claim This form may be used on all product claims except Group Term Life, Group Whole Life and AD&D claims. c)$el$_7T'R>`H4d?VZZ.6:FXa^5[8hKt_jJ5`+n^Hma14HF`L'+tk,U=9slnfp8]Z?2MS[;()=`R
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>> 0000000009 00000 n No Yes Ifyes,pleasecompletethefollowingquestionsrelatedtotheinjury . !7O$KXr'tSP>! 0000054815 00000 n Q[WGEfLmSJlD4aAIQg]>]O"6oFV!6AQ*&I%W1?E?iS+o&0c^Yc&U1]$I6mp;f=sCk)`?#3^FVJTgJrGe_1^q4-mOnYK@c1T5eKoO`M^;`6u-:]MC=Xh]*G+XUYfH(M?5
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<> Apply to Behavior Technician, Para Educator, Family Service Counselor and more! 0000000932 00000 n ii0)@:9O(%@H%RrdWERj>N3*\BUO1i]tqg3/1[H/;eAHS(@In[U#O`g'CB(1Z@f9[-o$S-AZ%3&Ipb==
21 0 obj Get more info about Aflac for business owners.. Aflac promised to be here when you need us most and a big part of that promise is making the claims process easy. Read, signed and dated the Authorization for Release of Information? To file a life insurance, disability insurance, or absence claim, click the button below to access the member portal. "kt65Ko1TNq1+;X4?fH1W0SbI2D-F(6cs2(!E?1oM!HZ/`bJ.Cb4@4gWrBVNX,G01o;?NA0^%)?aS>EJ
<> Aflac Group Disability Claim Form_2020. Also, if you are filing during the first year of your coverage effective date, we'll need you to provide the information requested on the Pre-Existing Investigation Statement. p!WHg/S/1>qh13::;;66rN. ;:9bBtb9H]qk\bkhPfIu$"+1TVJFo3OYhdrtnn;;,mTF]?KG*]5oEoE,[rmic=
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